By Samuel Nordberg, PhD
Chief of Behavioral Health

Like many people, I have struggled with anxiety at times in my life. In my early twenties, it paralyzed me for a time. I felt guilt and shame at my inability to overcome my fear and anxiety. I thought myself a coward, who would never break the cycle of panic, avoidance, and fear that trapped me in my apartment. In the early 2000s there were so many things to be afraid of in New York City. I couldn’t find my way out on my own.

It took me about a year of hard work, courage, and training, but I did begin to get a handle on my anxiety. I started working as an EMT in Brooklyn, I enrolled in a psychology training program at Columbia University, and gradually built the skills and confidence to manage my anxiety. It never left. I still manage it today – but my life is full, and rich, and happy.

Now, one of my favorite clinical activities is running a therapy group called Anxiety Skills 101. To be fair, it’s really more of a class than a group. In it, I try to tell folks all the things I wish I had known when my anxiety started spiraling out of control. We work together to build understanding, and practice skills for managing anxiety and worry. In the last month of the class, members take their skills out for a spin by challenging themselves to do something that their anxiety has prevented them from doing. I have witnessed poets deliver their work to audiences for the first time, heard singers perform, and watched business folks get on a plane for the first time in years. The group reminds me of my own struggles and triumphs, and I’ve condensed some of the major themes here.

Here’s what I wish I had known about anxiety right from the very beginning:

Nothing is broken.

In the anxiety skills class that I run, group members often comment, “It is so helpful to see other people who are struggling with the same thing I am and don’t seem broken.” Right now, roughly 1 in 5 Americans are quietly struggling with an anxiety disorder and are so good at covering it up that most people have no idea. If you are one of them, know you are not alone. Know, also, that there’s nothing fundamentally wrong with you – your anxiety system is just out of whack.

Anxiety is a natural product of a cognitive system (worry and fear) and a physiological system (adrenaline and cortisol) that was evolutionarily designed to keep us safe. Almost every human experiences anxiety on a spectrum. Some of us are more anxiety sensitive than others – meaning that we feel it more intensely, or have a system that triggers earlier than others might. But we all feel anxiety, and feeling anxious isn’t the problem. It’s as natural as breathing.

Here’s what’s happening when you feel anxiety: your brain identifies something it perceives as a threat (could be a tiger, could be a meeting with your boss, the list is infinite); your brain tells your body that there is a threat to your safety by activating the threat-response system we all have; then your body floods with adrenaline which triggers a physiological response designed to help you fight the threat or run from it. Your heart rate surges, and blood flows from your brain, gastrointestinal system, and reproductive system, into your major muscle groups (this can feel like jitters, tingles, a sense that you have to DO SOMETHING; often people misinterpret this as a heart-attack). You automatically begin breathing up in your chest, to draw extra oxygen (this can result in light-headedness, dizziness, and pain in the center of your chest).

All of these physiological changes would be great if you had to run from a tiger, but they’re really unhelpful if you’re trying to focus on a speech, or keep your cool in a meeting with your boss. In today’s world, there are so many scary things that aren’t threats to our physical safety, yet we will have the same powerful response we did 10,000 years ago. So, all this to say, first and foremost, there is nothing wrong with you when you feel anxiety. You aren’t broken.

Here’s how things go wrong.

Often, our amazing threat-response system becomes a problem. This is critically important to understand, because once we understand our own unique anxiety, we can then understand the best way to deal with it.

We often build up threats in our mind to the point where our anxiety about them is overwhelming. Let’s say we worry about attending a social event – meaning that our brain conjures up scenarios (like being embarrassed, or not knowing what to say and being judged) – that produces fear. That fear, as the event grows closer, can activate your threat-response system (which is designed to protect you from what you fear) and flood you with adrenaline. Blood flows, heart rate surges, you breathe faster… it all feels pretty awful. And a sneaky habit forms – you decide not to go, or to leave early. And, you feel relief! Our brains are smart, and designed to learn. When you feel relief, your brain says, “A ha! Avoiding the social event made us feel better. Let’s reinforce the neural pathways that made that happen.”

The next time a social event looms, your brain is ready with the solution – “Don’t go! We felt awful the last time we went. Staying home is better!” You stay home. You feel relief again. The reinforcement machine that is our brain can slowly, through multiple repetitions, or suddenly, through one terrible example, increase the amount of threat you associate with something – in this case, social events. This increased fear results in increased threat-reaction, which makes us want to avoid the situation even more. When we avoid, we reinforce the fear. Over time, this becomes stronger and stronger. Our world shrinks. Our ability to challenge our fear diminishes. We start seeing tigers all over the place and, without making a conscious decision to do so, we have built up our fear, anxiety, and avoidance to the point where they interfere with our lives.

All of this happens subtly, and not because our threat-response system is broken, but because we are using it for the wrong threats.

All of this is reversible.

I wish, more than anything, someone had told me this when I began to struggle with my own anxiety. Instead, I had a psychiatrist tell me that my anxiety would have to be managed with drugs for the rest of my life. Not true. While medications are a viable way to take the edge off of anxiety in the short-run, they are not required for anxiety management once you build the skills necessary to do so.

Anxiety is one of the things we are better off treating with education and skill training. With a therapist, an app, or a book as your guide and coach, you can develop an understanding of your anxiety and then build a training plan to help you deal with it. In my anxiety skills group, I try to equate this to weight lifting. If your goal is to become stronger, you set a clear target and you make a plan to get there. You start with lower weight, and then you start increasing weight gradually, until you hit your goal.

Managing anxiety is no different. It requires good form (skills and understanding), a sound plan (how you will gradually expose yourself to your fears without overwhelming yourself), and a lot of practice. Some of us can do it on our own. Some need a group, or a coach (therapist) to help guide them. The bottom line is this: if you put in the work, you will get better at managing your anxiety.

Never stop trying.

Don’t give up. Anxiety is, by its very nature, frightening and intimidating to take on. Facing our fears is hard, when so much of our instinct (and innate programming) is to avoid things that make us afraid. It may take you years to figure out what skills and changes work for you (it took me three) but it will be worth it. Don’t settle for a life where your excellent brain and threat-response system runs amok with your goals and happiness.

I am not suggesting that we can eliminate anxiety – I still have a panic attack every two years or so – but I am saying that we can manage it to the extent that it doesn’t rule our lives. It takes work – hard work. So don’t give up. Keep looking for allies, and mentors. Find a coach to keep you accountable. Treat it like a sport, or like learning a language. Don’t expect immediate results. Expect to be rewarded for hard work and repetition.

Here’s a place to start: we’ve recorded 12 podcast versions of my anxiety skills group, condensed to 30-minute segments, which are free to you here. These cover the “greatest hits” of the skills and knowledge that help most with anxiety management. The podcasts require daily work on your part, but all the handouts and worksheets are available here. Give it a look and see if it fits your style of learning. If not, we in Behavioral Health are rolling out more anxiety skills classes, run by different folks, so that more Reliant patients can engage in that work. Let your primary care provider know you’re interested, and we’ll work on getting you connected with one that works for your schedule.